Compliance with QMB Billing Rules and Guidance on Navigating Billing Procedures for QMB Patients

The Qualified Medicare Beneficiary (QMB) program, which offers Medicaid coverage for Medicare Part A and Part B premiums and cost-sharing to low-income Medicare beneficiaries, can be difficult to understand. The following points help clarify billing rules for healthcare providers regarding QMB patients.

Key points include:


1. Program Overview: QMB provides Medicaid coverage for Medicare expenses to eligible low-income individuals. In 2016, about 7.5 million beneficiaries were enrolled in the program, with different levels of Medicaid coverage.

2. Billing Requirements: Providers, regardless of whether they accept Medicaid, must not charge QMB individuals for Medicare cost-sharing (deductibles, coinsurance, and copays) for covered services. Pharmacists can still collect copayments for Part D prescription drugs.

3. State Medicaid Payments: Providers can seek payment for Medicare cost-sharing from State Medicaid Programs, though states often limit these payments. QMB individuals have no legal obligation to pay Medicare cost-sharing amounts.

4. Compliance Steps: Providers should establish processes to identify QMB status before billing, ensure exemption from Medicare charges, and seek payment from State Medicaid Programs when applicable.

5. QMB Status Identification: Providers can verify QMB status through Medicare eligibility data, remittance advice, Medicaid systems, or other documentation.

6. Advance Beneficiary Notices (ABN): Special guidelines apply when issuing ABNs to dual eligible beneficiaries. Providers cannot bill dual eligible beneficiaries pending adjudication by both Medicare and Medicaid.

7. Statutorily Excluded Services: Providers may bill QMB beneficiaries for services not covered by Medicare if Medicaid coverage is not available. Medicaid may cover excluded Medicare services if state policy allows and the provider participates in Medicaid.

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